Job Description

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

The Pre-authorization Specialist implements, maintains and executes procedures and processes by which Optum performs its referral and authorization process. This position responds to inquiries from patients, staff and physicians pertaining to referral authorization questions. The position also researches medical history and diagnostic tests when requested, to assist in review, processing, and coordination of prospective, concurrent and retrospective referrals.

This position is full time, Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 7:00am - 4:30pm Monday - Thursday and 8:00am - 12:00pm Friday PST. It may be necessary, given the business need, to work occasional overtime.

We offer on-the-job training. The hours of the training will be aligned with your schedule.

If you are located within the state of Washington OR Oregon, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

Initiate Referral Authorizations

• Acquires and maintain a working knowledge of Optum contracted health plans agreements and related insurance products
• Provides administrative and enrollment support for team to meet Company goals
• Gathers information from relevant sources for processing referrals and authorization requests
• Submits authorization & referral requests to health plan via avenue of insurance requirement. Including but not limited to website, phone, & fax
• Track authorization status inquires for timely response
• Maintains strong understanding of and educate our physicians, clinical teammates, patients and families regarding contracted health plans requirements related to Referrals/Pre-authorization Management
• Acts as a liaison between providers, teammates, outside vendors, health plans, community services and patients to support Referrals/Pre-authorization management process and requirements
• Reviews benefit language and medical records to assist in completion of requested services, to meet health plan requirements
• Documents patient information in the electronic health record following standard work guidelines
• Coordinates with Clinical teammates and health plans to identify patients with Referrals/Pre-authorization Management needs
• Provides member services to all patient group
• Answers referral and authorization inquiries from health plans, our clinical areas, patients and outside Optum Physician office/facilities
• Assists in the development and implementation of job specific policy and procedures
• Assists in the collection of information for member and/or provider appeals of denied requests
• Identifies areas for potential improvement of patient satisfaction

Review Denied Claims (No Authorization/No Referral)

• Researches root causes of missing authorization/referral
• Processes no authorization, no referral denied claims based on Insurance plans billing guidelines
• Obtains retro authorizations, appeals denied claims, or writes off charges based on Optum charge write-off guidelines
• Provides feedback and follow up to clinical areas and appropriate parties
• Assists in the development and implementation of job specific policies and procedures to reduce no authorization no referral denied claims to increase revenue
• Initiates improvement in authorization timeliness, accuracy and reimbursement

Utilization Management Medical Review:

• Processes Insurance plan referrals in EPIC
• Utilizes Prior Authorization list, MCG, NCCN, and individual insurance plan medical guidelines/policies to determine administrative review, what is needed for clinical review, and manages the work flows accurately
• Reviews clinical records to match insurance medical guidelines/policies, acquires additional records if necessary
• Discuss medical guidelines with insurance plan to reduce referral/prior authorization denial rate, expedite referral authorization process, and to keep peer to peer opportunities to minimal
• Document accurately and timely in medical record
• Processes referrals in timely manner to improve patient’s satisfaction

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• High School Diploma / GED
• Must be 18 years of age OR older
• 2+ years of experience in healthcare, including understanding of health plan related operations
• Experience in Referrals/Pre-authorization Management/Claims billing
• Experience with computer and Windows PC applications, which includes the ability to learn new and complex computer system application
• Experience with Microsoft Outlook, Microsoft Word & Microsoft Teams
• Experience with EHR/EMR systems (Epic)
• Ability to travel up to 10% of the time
• Ability to work full time. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 7:00am - 4:30pm Monday - Thursday and 8:00am - 12:00pm Friday PST. It may be necessary, given the business need, to work occasional overtime.

Preferred Qualifications:

• 1+ years of experience in Referrals/Pre-authorization Management
• 1+ years in appeal writing and processing
• 1+ years working knowledge of EOB, COB, Remits, and CMS 1500
• Knowledge of organizational policies, procedures, & systems
• Working knowledge of CPT & Diagnosis Coding, Medical Terminology, and basic Anatomy

Telecommuting Requirements:

• Reside within the state of Washington OR Oregon
• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy.
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.

• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

The hourly range for this role is $16.88 to $33.22 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

OptumCare is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

#RPO

Job Tags

Similar Jobs